ORIGINAL PAPER

An extra-articular procedure improves the clinical outcomein anterior cruciate ligament reconstruction with hamstringsin female athletes

Antonio Pasquale Vadalà & Raffaele Iorio &

Angelo De Carli & Alberto Bonifazi & Carlo Iorio &

Andrea Gatti & Cristina Rossi & Andrea Ferretti

Received: 25 April 2012 /Accepted: 28 April 2012 /Published online: 24 May 2012# Springer-Verlag 2012

AbstractPurpose A positive glide is a common finding after ACLreconstructions, especially in women. The aim of this studywas to prospectively evaluate the role of Cocker-Arnold’sextra-articular procedure in reducing the incidence of aresidual postoperative rotational knee laxity.Methods Sixty patients affected by an ACL injury with a +2(clunk) or +3 (gross shift) pivot-shift test entered this pro-spective study; they were randomly assigned to group A(control group, hamstrings) or group B (study group, ham-strings plus Cocker-Arnold). Thirty-two patients enteredgroup A and 28 group B. At follow-up, patients underwentclinical evaluation, KT-1000 arthrometer and Lysholm,Tegner, VAS and subjective and objective IKDC form.Results At a mean follow-up of 44.6 months, the sameexpert surgeon reviewed 55 patients (28 group A and 27group B). The comparison of the results of the evaluationscales used and of the KT-1000 arthrometer did not showstatistically significant differences (p>0.05). Lachman testwas negative (S/S) in all the patients of both groups(100 %). A residual positive pivot-shift (glide) was foundin 16 patients (57.1 %) of group A and in five patients(18.6 %) of group B (p<0.05).Conclusions The extra-articular MacIntosh proceduremodified by Cocker-Arnold in combination with ACL

reconstruction significantly reduces the rotational insta-bility of the knee.

Introduction

Today more women are participating in competitive andrecreational sports activities, with a concomitant higherincidence of ACL injuries in female athletes [1–7]. Manyauthors [1, 8–11] have already shown how postoperativeresults are usually worse in women than men after ACLreconstruction with hamstrings (HS). Even though someauthors [12–15] have stated that a greater postoperative kneelaxity in women does not necessarily correlate to poorerclinical results, it is a matter of concern as to what will bethe clinical outcome of such patients in long-term follow-up.

The role of extra-articular procedures improving postop-erative knee stability has been a matter of debate, especiallywith regard to the rotational component (glide); and whileauthors such as Roth et al. [16], Strum et al. [17] and Barretet al. [18] found no significant improvements with the use ofextra-articular plasty, Lerat et al. [19], Noyes et al. [20] andZaffagnini et al. [21] found an increased success rate withthe addition of an extra-articular procedure.

In order to better understand the real, effective, stabiliz-ing role of extra-articular procedures in ACL reconstructionin females, we carried out a prospective randomized study inwhich we compared two groups of active female patientstreated with autogenous four-strand hamstrings either with-out or with an extra-articular procedure. We also sought toexamine the relationship between postoperative residuallaxity and self-reported functional results.

A. P. Vadalà (*) : R. Iorio :A. De Carli :A. Bonifazi :C. Iorio :A. Gatti :C. Rossi :A. FerrettiOrthopaedic Unit and “Kirk Kilgour” Sports Injury Centre,S. Andrea Hospital, University of Rome “La Sapienza”,Via Grottarossa 1035,Rome (RM), Italye-mail: anto.vada@libero.it

International Orthopaedics (SICOT) (2013) 37:187–192DOI 10.1007/s00264-012-1571-0

The null hypothesis was that the use of a peripheral plastyin addition to ACL reconstruction with hamstrings provideshigher knee stability than ACL reconstruction alone.

Materials and methods

Between January 2005 and December 2006, 124 femalepatients were operated on for chronic ACL instability at ourOrthopaedic Department. Inclusion criteria to enter this studywas the presence of a moderate to severe rotatory instability asrevealed by a pivot-shift test graded as +2 or +3 (in a laxityscale ranging from score 0 negative, +1 glide, +2 clunk, to +3gross shift), a minimum interval of two months betweentrauma and surgery and an age less than 40 years old. Exclu-sion criteria were previous surgical procedures on the same oron the contralateral knee, with concomitant injury of theinternal or the external collateral ligament; concomitant sys-temic diseases; pre-operative radiological signs of knee arthri-tis; and imaging evidence of grades III or IV chondral damageon both patellar surface or medial and lateral femoral con-dyles, according to the International Cartilage Repair Society.On the contrary, the presence of concomitant medial or lateralmeniscal lesions was not considered an exclusion criterium.All patients included in the study were pre-operatively evalu-ated by the same expert surgeon (A.F.).

Out of the 124 operated, 60 patients were recruited toenter this prospective study and were consequently desig-nated by a draw to group A (32 patients, ACL reconstruc-tion with hamstrings) or group B (28 patients, ACLreconstruction with hamstrings plus extra-articular MacIn-tosh procedure modified by Cocker-Arnold).

The mean age of the patients at the time of surgery was27 years (range, 15–40 years). In group A the right side wasinvolved in 15 (46.8 %) cases and the left side in 17(53.2 %), while in group B the right side was involved in16 (57.1 %) cases and the left side in 12 (42.9 %).

Pre-operatively all patients were clinically evaluated withthe Lachman test [22] which was graded (S/S) as: 0, nega-tive; +1, negative but with a slightly longer endpoint; +2,positive. The pivot-shift test [19] was also tested and gradedas 0, negative; +1, glide; +2, clunk; +3, gross shift). Allpatients had a normal range of motion. Patients were alsogiven the Lysholm knee score [15, 23], Tegner activitylevel [24] and International Knee Documentation Com-mittee (IKDC) 2000 forms [25]. Joint laxity was assessedwith the KT-1000 arthrometer (MED Metric Corp., SanDiego, CA, USA) by measuring the side-to-side (S/S)differences in displacement at manual maximum (MM)testing.

All patients considered in this study were involved insports activity either as professionals or as amateurs. Theyall gave their informed consent to participate in the study.

Surgical technique

In patients of both groups, the ACL reconstruction consistedof an anatomical Out-In technique, with autogenous semite-ndinosus and gracilis tendons passed from the femoral to-ward the tibial side and securely fixed with biomechanicallyproven nonabsorbable fixation devices [26, 27]. While therecovery of knee stability in patients of group Awas entirelyachieved by reconstruction of the torn ACL with four-strandhamstring tendons, the patients of group B were operated onwith an additional extraarticular MacIntosh modified Coker-Arnold procedure. After slightly extending the lateral fem-oral incision (used to pass the new ACL ligament through)toward the Gerdy’s tubercle, a strip of iliotibial tract, ap-proximately 8–10 cm long and 1 cm wide, was obtainedfrom the iliotibial band. The strip was then proximally cutfree and passed under the lateral collateral ligament (LCL)in an anterior-to-posterior direction, then looped back onitself and sutured to the Gerdy’s tubercle with #0 Vycrilsuture, while the knee was flexed and in maximal externalrotation. The iliotibial tract was also sutured to the LCL foradditional stability (Fig. 1).

Rehabilitation protocol

The postoperative protocol was the same for all patients ofboth groups. The knee was locked in full extension with theuse of a brace, in order to protect the reconstructed ACL, tofacilitate its integration within the bone tunnels and thusavoiding the bone tunnel enlargement. Partial weightbearing

Fig. 1 Extra-articular MacIntosh modified Coker-Arnold procedure

188 International Orthopaedics (SICOT) (2013) 37:187–192

was allowed the second postoperative day, with the use oftwo crutches, as well as isometric exercises and hamstringsstretching. Recovery of range of motion was started at theend of the second postop week, when the brace wasunlocked to 0–90°. At the beginning of the second postopmonth the brace was completely removed, and the patientstarted a progressive program of muscular strengthening andrecovery of the remaining degrees of flexion. Return tosports activity was allowed starting from the fifth postopmonth.

Follow-up evaluation

All patients were followed-up at a mean of 44.6 months(range, 36–50). Out of the 60 patients pre-operatively con-sidered in this study, 55 were available for final follow-up:28 patients for group A and 27 for group B. An independentexaminer (A.V.), not involved in any of the surgical proce-dures, performed the physical examination of all patients.Subjectively, patients reported a visual analog scale score(VAS score of 0, no pain; 10, unbearable pain) and wereasked to judge the clinical outcome of the surgical procedurethey had undergone. Objectively, they underwent physicalexamination using the Lachman test, pivot-shift test, andevaluation of ROM (side-to-side). Moreover they underwentthe Tegner scale, the Lysholm knee score and IKDC 2000score, and were given the manual maximum KT-1000arthrometer test.

Statistical method

Statistical analysis was performed using SAS software (version9.1). The results between the two groups have been comparedthrough the Wilcoxon test and the chi-square test; the relation-ship between variables have been assessed through logisticmodels. A P value of less than 0.05 (5 %) was interpreted asbeing a significant difference between variables.

Results

All patientswere called for follow-up at amean of 44.6months(range, 36–50). No postoperative complications (such as in-fection, deep venous thrombosis or nerve injuries) weredetected in either of the two groups.

Group A, without extra-articular procedure

Out of the 32 patients of group A, four patients were notavailable for follow-up: two patients (6.2 %) because of areported re-rupture of the ACL (which occurred in one caseduring a soccer match and in the other case during a vol-leyball match), and the other two (6.2 %) because of living

too far away from our city. As a consequence, we followed-up28 patients of this group. The mean follow-up was43.1 months (range, 36–50). The mean age of this groupwas 28 years (range, 15–40 years). Six patients (21.4 %)underwent a medial partial selective meniscectomy, threepatients (10.7 %) an external partial meniscectomy, and twopatients (7.1 %) a concomitant medial and lateral partialmeniscectomy. Subjectively, the mean VAS score was 0.96±0.8 (range 0–3); 20 patients (71.4 %) judged their clinicaloutcome as excellent and eight patients (28.6 %) judged theirsas good. At physical examination, the Lachman test wasjudged as negative in 20 patients (71.4 %), and as +1 in eightpatients (28.6 %). The pivot-shift test was judged negative in12 patients (42.9 %) and positive in 16 patients (57.1 %), inspecific, a grade +1 pivot-shift test was detected in 12 patients(42.9%) and in the other four patients (14.2%) a grade +2wasfound (Fig. 2). However, all patients reported a satisfactoryfeeling of stability in the operated knee, despite the result ofthe pivot-shift test detected at physical examination. Finalrange of motion was complete (S/S) in all patients. Theaverage score of the Tegner scale decreased from a pre-operative value of 7.4±1.24 to 6.7±1.35 at follow-up; themean value of the Lysholm scale raised from 56.3±3.12 to94.5±6.65. The mean value of the objective IKDC form atfollow-up was 93.7±3.38, specifically, 21 patients (75 %)entered level A and seven patients (25 %) level B. Thesubjective IKDC score improved from 72±2.3 points (range,51–100 points) to 87±1.8 points (range, 54–100 points). Themean anterior laxity difference between the involved knee andthe contralateral healthy knee dropped from 10.2±0.77 mm to2.8±0.77 mm at maximum manual handling.

Fig. 2 Pre- and post-operative Pivot-Shift values

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Group B, with extra-articular procedure

Out of the 28 patients of group B, one patient was not ableto be present because he moved away for work purposes. Asa consequence, we followed-up 27 patients of this group.The mean follow-up was 45.2 months (range, 38–50). Themean age of this group was 26 years (range, 15–40 years).

Seven patients (25.9 %) underwent an internal partialselective meniscectomy, and three patients (11.1 %) anexternal partial meniscectomy. Subjectively, the mean VASscore was 1±0.86 (range 0–3); 19 patients (70.3 %) judgedtheir clinical outcome as excellent and eight patients(29.7 %) judged theirs as good. At physical examination,the Lachman test was judged as negative in 16 patients(59.3 %) and as +1 in 11 patients (40.7 %). The pivot-shifttest was judged as negative (grade 0) in 22 patients (81.4 %)and as positive (grade+1) in five patients (18.6 %) (Table 1).All patients of group B reported a satisfactory feeling ofstability in the operated knee. Final range of motion wascomplete (S/S) in all patients. The average score of theTegner scale decreased from a pre-operative value of 7.9±0.88 to 7.5±1.15 at follow-up; the mean value of theLysholm scale raised from 53.4±4.22 to 95.8±3.99. Themean value of the objective IKDC form at follow-up was94.2±3.33; 22 patients (81.4 %) entered level A and fivepatients (18.6 %) level B. The subjective IKDC score im-proved from 71±1.2 points (range, 49–99 points) to 89±1.5points (range, 61–100 points). The mean anterior laxitydifference between the involved knee and the contralateralhealthy knee dropped from 10.9±0.7 mm to 2.7±0.89 mmat maximum manual handling.

Comparison of data (Table 1) between the two groupsshows similar results in regard to all the variables consideredexcept for the pivot-shift test, which was negative (grade 0) inthe vast majority of patients of group B (81.4 % vs. 42.9 ofgroup A). Analysis of the logistics model clearly shows howthe "postop pivot-shift" variable was highly correlated (p00.001) to the group in which patients belonged.

Discussion

The most important finding of this study was the statisticallysignificant better results we gathered in the group of femalepatients operated on for ACL reconstruction in which aperipheral plasty was added with the aim to further reducethe rotatory instability of the knee. In fact, because of theresults published by many authors showing less successfulresults in female patients than in male patients [1, 9, 11], wecarried out this study in order to well define the effective-ness that an additional extra-articular tenodesis might havein preserving the reconstructed ACL, and reducing the post-operative rotatory instability in female patients. In this studywe aimed to assess the efficacy of an additional extra-artic-ular plasty in reducing the potential postoperative rotationallaxity. The hardest part of this study was to gather a homog-enous group of patients to follow. The entity of joint laxityhad the potential for being very wide among the femalepatients we wanted to examine; for this reason we decidedto accurately examine the patients before the operation andto consider only those patients whose pre-operative rotation-al laxity was graded as +2 or greater. The same authorevaluated all the patients selected for this study by testingthe rotational instability of the knee with the pivot-shift test.This selection criteria was done with the aim of having ahomogeneous group of patients to follow up. The lack ofthis type of selection would have made the group of patientsvery heterogeneous with low evidence-based reliability. Asdescribed above we carefully followed the inclusion/exclu-sion criteria in order to avoid potential bias due to concom-itant lesions, such as internal or external collateral injuries orchondral damages. The rational of combining intra- andextra-articular procedures in ACL reconstruction is to re-strict the internal rotation of the reconstructed knee, thusproviding more stability in the knee in the rotational axisand preventing the ACL graft from undergoing further ex-cessive stress. Many studies have already investigated therole of such extra-articular procedures [16, 17, 19–21, 28,29]. Anderson et al. [30], as well as Roth et al. [16], showedno improvement by the addition of an extra-articular proce-dure. Completely different conclusions were shown by Leratet al. [19] and Noyes et al. [20], which showed the results oftwo prospective studies with significantly better results inpatients with an extra-articular procedure. More recently,Monaco et al. [30], using a navigator system demonstratedthat the addition of a lateral extra-articular tenodesis proce-dure to a standard single bundle ACL reconstruction wasmore effective in reducing the internal rotation of the tibia,when compared with a standard single bundle ACL recon-struction or with an anatomic double bundle reconstruction.In our experience, we registered two cases of failure amongpatients without peripheral tenodesis and no cases amongpatients with the extra-articular procedure. The results of our

Table 1 Methodology used to value the difference between the twogroups referring to the variable, the statistic value and the related type Ierror

Variable Methodology Value P

Pivot-shift Wilcoxon 2.7397 0.0031

Lachman Chi-square 1.2528 0.263

Tegner Wilcoxon 0.5157 0.302

Lysholm Wilcoxon 1.8443 0.062

Sub. IKDC Wilcoxon 1.7837 0.087

Obj. IKDC Wilcoxon 0.2753 0.391

KT-1000 MM Wilcoxon 2.3549 0.402

VAS Wilcoxon 0.1499 0.4404

190 International Orthopaedics (SICOT) (2013) 37:187–192

study show no significant differences between the twogroups with regard to subjective postoperative feeling of kneestability or objective evaluation scales performed. However,patients of group B showed a significantly higher percentageof negative (grade 0) pivot-shift test results compared to groupA, which might be due to the presence of the additional extra-articular procedure performed. Moreover, while two patientsof group A experienced a rerupture, this data did not occuramong patients of group B. Among the evaluation scales used,while the Lysholm and the IKDC showed significant betterresults at follow-up, the Tegner scale showed lower results inboth groups, although without a significant difference be-tween the two groups. This might be due to the fact that notall the patients included in this study were regularly practicingsports activity and the score they chose was a consequence ofresidual fear to return to the pre-operative sport activity level.Themain drawback of the study is certainly represented by thehighly subjective capability of judging the pivot-shift test;however, because of the lack of standardized objective teststhat exist to test the rotatory instability of the knee, our bestoption was to have an independent expert examiner whoblindly followed-up all the patients. Moreover, despite thehypothesized arthritic degeneration potentially arising fromthe use of an extra-articular procedure, we did not assess theradiological degeneration of the knee at follow-up; however,we never clinically reported signs of femoro-patellarsymptoms.

In conclusion, the combination of an extra-articularMacIntosh procedure modified by Cocker-Arnold with ACLreconstruction seems to significantly reduce the rotationalinstability of the knee.

Acknowledgement We would like to acknowledge Dr. GianlucaMastrantonio for the statistical analysis and Mrs. Angela Mitchell forthe technical support in performing the study.

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